A patient with a diagnosis of nodal marginal zone B-cell lymphoma and a t(2;14)(p24;q32) involving MYCN and IGH.

BACKGROUND: Nodal marginal zone B-cell lymphoma is a rare entity in which the cytogenetic findings are not well defined. The t(2;14)(p24;q32) has previously been reported in three patients with blastic mantle cell lymphoma and one patient with follicular lymphoma. This rearrangement has not been reported previously in a patient with a diagnosis of nodal marginal zone B-cell lymphoma. CASE PRESENTATION: We present a male patient who presented with lymphadenopathy. On the basis of his clinicoradiologic presentation, morphological appearances, immunophenotype and molecular findings he was determined to have a diagnosis of nodal marginal zone B-cell lymphoma. Cytogenetic analysis demonstrated a t(2;14)(p24;q32). Further FISH testing showed this rearrangement to involve the MYCN and IGH genes. CONCLUSIONS: We present the first patient with a diagnosis of nodal marginal zone B-cell lymphoma with a t(2;14)(p24;q32). This rearrangement has been described in three other patients who have had a diagnosis of lymphoma. Our findings suggest this rearrangement is not specific to mantle cell lymphoma or follicular lymphoma. The number of cases described are still too low to draw firm conclusions regarding the nature of this rearrangement. In order to refine the clinical and prognostic picture of this finding, publication of further cases is required.

Impact of a Cognitive Behavioral Intervention on Health-Related Quality of Life and General Heart Rate Variability in Patients Following Cardiac Surgery: An Effectiveness Study.

BACKGROUND: Although there is evidence supporting the efficacy of cognitive-behavioral therapy (CBT) in decreasing psychologic symptoms and improving health-related quality of life in patients who have undergone coronary artery bypass graft surgery, the effectiveness of these interventions in usual health care practice, and their effect on general heart rate variability (HRV), has not been tested. OBJECTIVE: This study investigated the effectiveness of CBT in improving health-related quality of life and HRV in patients with postcardiac surgery. METHODS: However, 2 months following surgery, 150 patients were assigned sequentially to a CBT group that received the intervention for 9 months or a comparison group that received usual care. Patients were assessed at baseline and after 10 months with the 36-item Short Form Health Survey. HRV was also assessed. RESULTS: In total, 43 patients in the CBT group and 46 in the usual care group completed the study. The CBT group demonstrated significant improvements in health-related quality of life and significant increases in general HRV. Significant group-by-time interaction effects were found for the several 36-item Short Form Health Survey scales and mental component summary and a time-domain HRV parameter indicating that the pattern of change in scores over time differed significantly between the 2 groups. CONCLUSION: CBT administered in a "real-world" clinical setting can effectively improve health-related quality of life and the general HRV in patients who have undergone cardiac surgery.

Pseudotumours and IgG4-related disease: a case report.

We report a case of a patient presenting with abdominal pain, weight loss and CT imaging showing mass lesions in the chest and abdomen associated with lymphadenopathy. He was diagnosed as having IgG4-related disease and responded well to steroid treatment.

Sensitivity and uncertainty in the measurement of H*(10) in neutron fields using an REM500 and a multi-element TEPC.

The REM500 is a commercial instrument based on a tissue-equivalent proportional counter (TEPC) that has been successfully deployed as a hand-held neutron monitor, although its sensitivity is regarded by some workers as low for nuclear power plant radiation protection work. Improvements in sensitivity can be obtained using a multi-element proportional counter design in which a large number of small detecting cavities replace the single large volume cavity of conventional TEPCs. In this work, the authors quantify the improvement in uncertainty that can be obtained by comparing the ambient dose equivalent measured with a REM500, which utilises a 5.72 cm (2(1/4) inch) diameter Rossi counter, with that of a multi-element TEPC designed to have the sensitivity of a 12.7 cm (5 inch) spherical TEPC. The results obtained also provide some insight into the influence of other design features of TEPCs, such as geometry and gas filling, on the measurement of ambient dose equivalent.

Depression predicts perioperative outcomes following coronary artery bypass graft surgery.

OBJECTIVES: To assess preoperative depression in middle-aged men undergoing coronary artery bypass graft surgery (CABG) and to determine if depression is related to perioperative outcomes. DESIGN: One hundred and nine middle-aged male patients were randomly selected and assessed for depression one day before CABG using the Symptom Checklist-90 Revised (SCL-90R). Perioperative outcomes were: (1) postoperative length of hospital stay, (2) the presence of any early complications (at intensive care unit), and (3) the presence of any late complications (at cardiac surgery unit). RESULTS: Twenty-five (23%) patients had a high level of depression. Preoperative depression scores significantly predicted postoperative length of hospital stay (p < 0.001) and the incidence of late perioperative complications (p < 0.05) independently from biomedical and sociodemographic factors. Each increase in depression T score increased the odds of occurrence of late complications by 10% (p = 0.018, CI 95% 1.02-1.19). CONCLUSIONS: Depression is common in middle-aged men undergoing CABG and is an independent predictor of postoperative length of hospital stay and late perioperative complications.

Molecular evidence for the identity of the Magenta petrel.

A lone petrel was shot from the decks of an Italian warship (the 'Magenta') while it was sailing the South Pacific Ocean in 1867, far from land. The species, unknown to science, was named the 'Magenta petrel' (Procellariiformes, Procellariidae, Pterodroma magentae). No other specimens of this bird were collected and the species it represented remained a complete enigma for over 100 years. We compared DNA sequence of the mitochondrial cytochrome b gene from the Magenta petrel to that of other petrels using phylogenetic methods and ancient DNA techniques. Our results strongly suggest that the Magenta petrel specimen is a Chatham Island taiko. Furthermore, given the collection location of the Magenta petrel, our finding indicates that the Chatham Island taiko forages far into the Pacific Ocean (near South America). This has implications for the conservation of the taiko, one of the world's rarest seabirds.

A case of cardiogenic shock caused by capecitabine treatment.

BACKGROUND: A 52-year-old woman underwent successful resection of stage IIB primary mucinous adenocarcinoma of the appendix and was started on capecitabine chemotherapy. Five days into the first course, after initially experiencing diarrhea, nausea, vomiting and a transient episode of retrosternal chest pain radiating to the left scapula, she presented to the emergency department with cardiogenic shock. INVESTIGATIONS: Electrocardiography, transthoracic echocardiography, laboratory investigation of cardiac biomarkers, coronary angiography and endomyocardial biopsy. DIAGNOSIS: Capecitabine-induced cardiogenic shock. MANAGEMENT: Supportive treatment with dopamine, milrinone, norepinephrine (noradrenaline) and levosimendan.

The challenge of chronic pain: a psychoanalytic approach.

Although patients with medically unexplained chronic pain are sometimes referred for psychiatric consultation, it is rare for them to be recommended for a psychoanalytically informed treatment. Moreover, because they experience their distress as primarily physical, it is difficult to engage such patients in psychoanalysis. Nonetheless, the psychoanalytic understanding of conversion symptom formation, and of how childhood trauma and adverse attachment experiences impact on the mind-brain-body-complex, can be integrated with the current neuromatrix theory of pain and thereby offer a comprehensive theoretical model and guide for the psychoanalytic treatment of some patients with chronic pain syndromes. The author illustrates this approach by reporting the analysis of a patient with chronic pelvic pain who had obtained no relief from a host of medical and psychiatric therapies. The analytic process of linking the pain with emotional trauma and pathologic internal object relations, and thereby symbolizing the pain, allowed the patient to discover multiple meanings for the symptom and make important life changes as the pain subsided.

Rheumatoid forefoot reconstruction: first metatarsophalangeal joint fusion combined with Weil's metatarsal osteotomies of the lesser rays.

This study evaluates the outcome of rheumatoid forefoot reconstruction with arthrodesis of the first metatarsophalangeal joint (MTPJ) combined with multiple Weil's metatarsal osteotomies (WMO) to the lesser rays. A retrospective study on 17 consecutive patients (26 feet) was performed with subjective, clinical, and radiological analysis. At an average follow-up of 26.2 months, patients rated the result in 88% of cases as excellent or good with 76% improvement in pain, 74% improvement in function, and 70% improvement in footwear. This corresponded with a high mean modified AOFAS score of 72/100 (34 to 90). First MTPJ arthrodesis union rate was 92%. Fourteen percent of lesser toes were aligned preoperatively compared to 86% at latest review. There was a 12% rate of recurrent metatarsalgia and or callosities. This combined procedure provides stabilization of the first ray, offloading the lesser metatarsals and preventing early recurrence of deformity. Preserving the lesser metatarsal head further widens the surgical options if revisional surgery is necessary in the future. ACFAS Level of Clinical Evidence: 4.

A case of Gorham's disease complicated by bilateral chylothorax.

Gorham's disease is a very rare disorder of uncertain aetiology, characterised by non-neoplastic proliferation of vascular or lymphatic channels within bone leading to resorption and replacement of osseous matrix with angiomatous tissue. Fewer than 200 cases have been reported in the literature. The complication of chylothorax is associated with a high morbidity and mortality. We present the case of a 17-year-old male with Gorham's disease of the sternum, clavicle and rib, complicated by bilateral chylothorax. Despite thoracic duct ligation and radiotherapy, the patient progressively deteriorated and died 36 weeks following initial presentation.

Medial impingement after ankle replacement.

Ankle replacements appear to offer a good alternative to fusion for most arthritic conditions. Use of mobile bearings has significantly improved results of ankle replacement. Ankle replacements still have a significant minor-complication rate which does not seem to affect the long-term outcome. Medial impingement as a complication has been reported with popular designs. We reviewed the senior author's first five years of Buechel-Pappas ankle replacements looking at AOFAS scores, VAS scores, patient satisfaction, learning curve of the surgeon and complications. Eight patients out of a total of 34 reported symptoms of medial impingement at follow-up. Four patients underwent revision surgery for this. Ankle replacements have a significant proportion of minor complications, one of which is medial impingement. Whether this is due to implant design, residual arthritis in medial recess or soft-tissue pathology is uncertain but revision surgery may be required.

The influence of alexithymia on persistent symptoms of dyspepsia after laparoscopic cholecystectomy.

OBJECTIVE: The aim of this study was to evaluate whether preoperative alexithymia might play a role in the persistence of gastrointestinal symptoms after laparoscopic cholecystectomy. METHODS: A sample of 52 consecutive patients with gallstone disease and symptoms of dyspepsia were assessed with validated scales for alexithymia (20-item Toronto Alexithymia Scale), and psychological (90-item Symptom Checklist) and gastrointestinal (GI) (Gastrointestinal Symptom Rating Scale) symptoms before surgery. GI symptoms were evaluated also one year after surgery. Change from preoperative to postoperative GI symptoms and level of GI symptoms after surgery were used to form groups of improved (n = 31) and unimproved (n = 21) patients. RESULTS: Unimproved patients had significantly higher preoperative alexithymia, psychological distress, and gastrointestinal symptom scores than patients who had improved. Regression analyses showed that alexithymia predicted the persistence of gastrointestinal symptoms more strongly than did psychological distress, even after controlling for preoperative gastrointestinal symptoms. CONCLUSION: Alexithymia played a substantial and predictive role in the persistence of GI symptoms in gallstone patients after surgery. Treatment planning and outcome of gallstone disease might be improved by preoperative assessment of alexithymia.

Genetic heterogeneity among intertidal habitats in the flat periwinkle, Littorina obtusata.

Comparisons among patterns exhibited by functionally distinct genetic markers have been widely used to infer the impacts of demography and selection in structuring genetic variation in natural populations. However, such multilocus comparisons remain an indirect evaluation of selection at particular candidate loci; ideally, the identification of a candidate gene by comparative genetic methodologies should be complemented by functional analyses and experimental manipulations of genotypes in the laboratory or field. We examined genotype frequency variation among replicated intertidal habitats at two spatial scales in the grazing snail Littorina obtusata. Both of the candidate allozyme markers varied predictably with environment, and these patterns were consistent at both spatial scales. Three of four reference loci were spatially homogeneous, but one microsatellite exhibited significant structure at both geographical and mesoscales. To initiate a direct examination of whether the observed genotype frequency variation at one of the candidate markers, mannose-6-phosphate isomerase (MPI), was impacted by differential survivorship of genotypes, we conducted a series of laboratory-based thermal stress assays using snails from two geographically disparate source populations. When snails were exposed to bouts of thermal/desiccation stress, patterns of mortality were nonrandom with respect to MPI genotype. Furthermore, patterns of mortality in the laboratory manipulation coincided with the observed distribution of genotypes in the field. The data suggest the operation of selection at the Mpi or a linked locus, but functional studies and further experimentation are required to establish the relationship between MPI genotype and fitness across heterogeneous intertidal environments.

Inflammatory fibroid polyps of the duodenum: a review of the literature.

BACKGROUND/AIM: An inflammatory fibroid polyp (IFP) is a rare benign submucosal gastro-intestinal lesion with an uncertain origin and natural history. An IFP was first described in the stomach and is rare in the duodenum. Presenting signs and symptoms vary according to anatomical site. This systematic literature review was prompted by the recent presentation of a patient with biliary obstruction caused by a duodenal IFP. METHODS: A review of all duodenal IFPs identified in the PubMed database from 1971 onwards is presented within the context of what is known about the lesion at other gastro-intestinal sites. RESULTS: Of approximately 1,000 IFP cases identified, 70% were of gastric origin, and fewer than 1% occurred in the duodenum. Duodenal IFPs typically present with non-specific features, and no pre-operative diagnoses of lesions at this site have been made. Microscopy reveals spindle-shaped cells, prominent capillaries, and an inflammatory cell filtrate. Immunohistochemistry shows the lesions to be CD34 and vimentin positive, but CD117, S100, and factor VIII negative. Local recurrence is most unusual following complete resection. CONCLUSIONS: This rare benign entity in the duodenum should be included in the differential diagnosis of all peripancreatic masses. The advent of endoscopic ultrasound may allow pre-operative diagnosis of the lesion in the duodenum, enabling local resection and potentially avoiding unnecessary pancreatoduodenectomy.

Heart transplantation in a patient with endomyocardial fibrosis due to hypereosinophilic syndrome.

Idiopathic hypereosinophilic syndrome (HES), a systemic disease that commonly involves the heart leading to progressive endomyocardial fibrosis, frequently manifests as restrictive cardiomyopathy. In this report, we describe the first case of a patient with endomyocardial fibrosis due to HES who underwent orthotopic heart transplantation at our institution. A literature review and discussion are included.

First metatarsophalangeal joint arthrodesis: a new technique of internal fixation by using memory compression staples.

A prospective clinical study of first metatarsophalangeal joint arthrodesis using memory compression staples is presented. In 27 patients, 30 feet underwent surgery. There were 24 women and 3 men, with a mean age of 61.2 years. Two memory compression staples were used at right angles to each other to achieve compression at the fusion site. Postoperatively, patients were allowed full weightbearing in a rigid-soled shoe. Subjective assessment was performed with a standard questionnaire, which included questions regarding level of pain, ambulation, and patient satisfaction. Objective assessment was performed by a clinical and included a radiographic examination. There was a postoperative reduction in the pain score from 4.6 to 1.6 (P < .0001). Ambulation ability improved from 4 to 2.5 (P < .0001). Patients reported 86.6% excellent to good results, and 96.7% achieved radiographic fusion at an average 8.2 weeks. The only significant postoperative complication was a single nonunion. The authors advocate memory compression staples for the internal fixation of first metatarsophalangeal joint arthrodesis. The implant is low profile, and postoperative cast immobilization is not required. The use of this device has a predictable success rate comparable to previously reported methods.

Fungal laryngitis in immunocompetent patients.

The diagnosis of fungal laryngitis is often overlooked in systemically immunocompetent patients because it is commonly considered a disease of the immunocompromised, and because it often mimics, clinically and histologically, more common and more serious conditions e.g. leukoplakia. A high index of suspicion is required to make the diagnosis, and should be considered in any immunocompetent patient with persistent or refractory laryngitis and factors predisposing to local mucosal barrier impairment e.g. gastropharyngeal reflux, smoking or inhaled steroid use. In such cases, demonstration of hyperkeratosis, particularly if associated with intraepithelial neutrophils, on biopsy should trigger a search for fungal elements using specialized stains. Prolonged treatment by systemic antimycotics is required. Treatment should also include the elimination of any predisposing factors, as failure to do so may result in difficulty with disease eradication or recurrence of the condition.